- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $977.24 / $2,041.74
| Facility | | $389.05 | $977.24 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $407.38 / $630.96
| Professional | | $338.84 | $407.38 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $524.81 / $2,187.76
| Facility | | $524.81 | $524.81 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $363.08
| Professional | | $208.93 | $208.93 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $436.52 / $489.78
| Professional | | $398.11 | $436.52 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $1,288.25 / $2,691.53
| Facility | | $524.81 | $1,288.25 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $323.59 / $851.14
| Professional | | $257.04 | $323.59 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $575.44 / $724.44
| Professional | | $524.81 | $575.44 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $575.44 / $891.25
| Facility | | $416.87 | $575.44 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $1,096.48
| Professional | | $199.53 | $199.53 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $741.31 / $10,000.00
| Facility | | $467.74 | $741.31 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $741.31 / $10,000.00
| Professional | | $467.74 | $741.31 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $524.81 / $630.96
| Facility | | $309.03 | $524.81 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $257.04 / $575.44
| Professional | | $218.78 | $257.04 | $575.44 |